13.9 Concealed Pregnancy

This is a gender neutral procedure informed by an anti-discriminatory and anti-oppressive value base.

The following terms are used:

Birthing person or pregnant person - anyone of childbearing capacity

Labouring person or person in labour

Person/people and they/them pronouns

This procedure is for anyone who may encounter a person who conceals the fact that they are  pregnant, or where a professional has a suspicion that a pregnancy is being concealed or denied, or a person significantly delays access to antenatal care. While concealment and denial, by their very nature, limit the scope of professional help, better outcomes can be achieved by a coordinating an effective inter-agency approach. This will also apply to future pregnancies where it is known or suspected that a previous pregnancy was concealed.

A concealed pregnancy is when a person knows they are pregnant but does not tell appropriate carers or professionals; or tells a carer/professional but actively conceals that they are not accessing antenatal care.

A denied pregnancy is when a person appears genuinely unaware that they are pregnant; A denied pregnancy is when a person is unaware of or unable to accept the existence of their pregnancy. Physical symptoms of pregnancy may be absent or not apparent or misconstrued; a variety of factors including intense psychological conflicts about the pregnancy may result in subconscious suppression where a person continues to think, feel and behave as though they were not pregnant.  

A late booking is defined as accessing maternity care after 20+0 weeks of pregnancy for the purposes of this safeguarding policy. It is important to remember that even when a person appears to have been genuinely unaware, they were pregnant, they have still concealed or denied their pregnancy up until the point they have accessed antenatal care. Once booked and accessing antenatal care, there should be ongoing assessment of any pregnancy where maternity care is accessed after 20+0 weeks of pregnancy, that considers the reasons for the delay in presentation and any other risk factors.

The first antenatal (booking) appointment with a midwife should take place by10+0 weeks of pregnancy (NICE 2021) therefore any person booked later than this is deemed to have booked late. It is important to highlight this distinction as the terminology used in practice is the same. Any person who accesses maternity care after 10+0 weeks of pregnancy should be asked about the reasons for this because it may reveal social, psychological or medical issues that need to be addressed.

A late booking is defined as presenting for maternity services after 20 weeks It is always important to remember that unless the person genuinely has not been aware they are pregnant they have still concealed their pregnancy up until the point they have accessed antenatal care. A booking appointment with a midwife should be around 10 weeks (NICE 2008). A person who presents to antenatal care late in their pregnancy should continue to be assessed with the reasons for the delay in presentation and associated risks as part of the assessment, even once booked and attending for antenatal care.

Although there are important distinctions, the term concealed pregnancy will be used throughout this policy to cover concealed pregnancy, denied pregnancy and late booking for maternity care.

• An Unassisted birth is when person gives birth without a midwife, doctor, or other trained health professional in attendance. There are two types of unassisted birth:Born Before Arrival (BBA) is when a pregnant person who had every intention of either having a hospital or planned home delivery with the help of a midwife and/or doctor and has engaged with maternity services in the planning of either, but where the birth of the baby has happened so rapidly that either the pregnant person or the midwife does not make it to the planned place of birth i.e., maternity unit or home.
• Free birth is when a pregnant person decides to give birth at home or somewhere else without the help of a midwife, doctor, or other trained health professional in attendance. Pregnant persons have a legal right to make informed decisions about their maternity care and can choose not to accept care during childbirth. However, it is a criminal offence for anyone other than a registered midwife or doctor to attend a person during childbirth except in an emergency. (Article 45 of the Nursing and Midwifery Order). Understanding the pregnant persons reasons for free birthing is critical to assessing safeguarding risk/level of need.

All professionals are responsible for supporting a pregnant person to access and attend antenatal care at the point a concealed pregnancy is disclosed or suspected.  Depending on the reasons given for concealment and/or denial, they may need support accessing specialist services such as mental health services, including referral to perinatal mental health care.

Action on Suspecting Concealed Pregnancy

Young People aged under 18

If the professional has a concern that a young person could be pregnant and not accessing antenatal care, then they should make a referral to Children's Social Care 13.1 Local Contact Details for the young person and a Child and Family Assessment will be carried out. All professionals need to be mindful of the reasons and associated risks that contribute to why pregnant persons may conceal their pregnancies see 8.10.6 and consideration given to safeguarding both the young person (under 18 years) and the unborn baby.

It may be appropriate for a professional from any agency to make initial approaches to the young person to discuss the possibility of them being pregnant, if their presentation and personal circumstances suggest this.  Professional curiosity is essential to safeguarding children but will require sensitivity. Professionals should consider requesting support from health colleagues.

If professionals are unable to engage the young person in constructive discussion, and continue to have clear reasons to suspect pregnancy in the face of continuing denial, then Children's Social Care should carefully consider if informing her parents/carers is in the best interest of the young person and continue to assess the situation with a focus on the needs/welfare of the unborn baby as well as the young person. Caution is required with all disclosures to a young person’s parents that a professional is not putting the young person at further risk, for example Honour Based Abuse.

Young people presenting late in pregnancy should be assessed by maternity services at the booking appointment and potential safeguarding risks/needs highlighted and considered in relation to safeguarding the young person (under 18 years) the unborn baby and any other children in household or family. This will inform the decision as to whether to refer to children’s social care, and consider what early help services could support the family.

Any staff member being made aware of possible pregnancy are always encouraged to approach health colleagues for advice, this could include the GP, midwife, school nurse or sexual health advisor for example.  The briefing sheet below identifies where professionals can obtain further advice.

Guidance on planning a conversation with a young person who might be pregnant

See also Pregnancy of a Child 

A pregnant person over 18

Where a person over 18 is thought to be pregnant, every effort should be made to resolve the issue of whether they are pregnant or not. The vulnerability of the adult needs to be considered and signposted to appropriate services, which may include adult social care.

No pregnant person can be forced to undergo a pregnancy test, or any other medical examination, but in the event of refusal with clear reasons to suspect the person is pregnant, professionals should proceed on the assumption that the person is pregnant until it is proved otherwise. A referral to children’s social care 13.1 Local Contact Details will be required for a multi-agency decision and assessment to ensure appropriate support and intervention are provided at the earliest opportunity and to make plans to safeguard the baby's welfare at birth. All professional referrals should include an assessment of safeguarding risk/need.

People presenting late in pregnancy, after 20 weeks gestation, should be assessed by maternity services at the booking appointment and potential risks/needs highlighted and considered in relation to safeguarding the unborn baby and other children within the household or family. This will then inform the decision if referral to children social care is required and what early help services would support the family where appropriate.

Actions on concerns that someone is concealing their pregnancy

Multi-agency liaison should occur involving the GP, midwife, health visitor and any other relevant agency to assess the information and to construct a plan.

It may be appropriate to invite a representative from Mental Health Services (child or adult as appropriate) so that support, advice and/or consultation are available at an early stage.

Where there are additional concerns, e.g. lack of engagement, possibility of sexual abuse, or substance misuse, the referral should be considered under child protection procedures (see Section 47 Enquiries Procedure), which may include convening a pre-birth Child Protection Conference (see Pre-Birth Child Protection Procedure).

Underlying reasons

It is acknowledged that there are situations where a pregnant person appears to have been unaware of their pregnancy until the unexpected birth of a baby but adjust quickly to this and can parent safely and effectively. However, this is not always the case therefore possible underlying reasons for concealing the pregnancy must always be fully explored.

The reason for the pregnancy being concealed or denied will be a key factor in determining the risk to the unborn baby/child and any other children in the household or family; these reasons can include but are not limited to; unwanted pregnancy, mental illness, domestic abuse, substance misuse, learning disability, sexual abuse or exploitation, fear of social services involvement, religious and/or cultural beliefs, desire to minimise or avoid medicalisation of childbirth, and incestuous or unknown paternity or where paternity is the result of rape or infidelity. Issues such as these may present a risk to the pregnant person and/or the unborn baby/child, as well as other children in the family.

Professionals need to consider any potential vulnerability of the pregnant person and impact on their baby. Research does not suggest that pregnant persons at risk of care proceedings avoid maternity care. However, children’s social care history should always be considered when seeking to understand reasons for concealed or denied pregnancy and assessing level of safeguarding need/risk.

There may be risks to both the pregnant person and the unborn baby/child if they concealed or denied the pregnancy due to fear of disclosing the paternity, for example where the unborn baby/child was conceived as the result of sexual abuse or exploitation, or where the unborn baby/child is not the biologicy baby/ child of the person's partner.

Young people may conceal or deny their pregnancy due to fear of negative and/or unsupportive reactions from others, such as their partner, parents/carers, peers and/or professionals.

Refugee, asylum seeking, and undocumented migrant pregnant persons face multiple barriers to accessing maternity care which should be considered as part of a wider holistic safeguarding assessment in the event of concealed pregnancy. This includes differing expectations of maternity care from their country of origin, language barriers, having care refused or delayed due to immigration status, being charged for maternity care despite having no ability to pay and multiple moves within asylum system accommodation. An interpreter should always be used where language is a barrier to effective communication.

Late booking can be the result of a person presenting for a termination of pregnancy but being unable to have this procedure as the pregnancy is over 24 weeks gestation. When assessing the level of safeguarding need/risk, professionals should consider the pregnant persons reasons for requesting a termination of pregnancy, accessing termination of pregnancy services late, the impact of continuing with an unwanted pregnancy on bonding, attachment and parenting capacity and any additional or associated risk factors.

Pregnant people continuing with an unwanted pregnancy are likely to need a high level of practical advice and both emotional and psychological support to enable them to decide whether to parent the child themselves or arrange for adoption or fostering. Where the plan is to parent the child themselves, interventions should commence as early as possible in pregnancy to promote parental bonding and continue after the baby is born to optimise infant attachment. Consideration should be given to a children’s social care referral - 3.2 Making a Referral | Sussex Child Protection and Safeguarding Procedures Manual

Implications 

The implications of concealed pregnancy are difficult to predict and wide-ranging.

Chid Practice Safegurading Reviews (reviously Serious Case Reviews) consistently highlight an association between children being seriously or fatally harmed and concealed pregnancy. This is the case, regardless of the birthing persons intention.

Concealing a pregnancy can indicate ambivalence towards the pregnancy, inability to prioritise the unborn baby/child over the pregnant persons own needs, immature coping styles and/or a tendency to dissociate, all of which are likely to have a significant impact on bonding, attachment and parenting capacity.

Potential implications of concealed pregnancy include:

• Pregnant persons may not receive important health and lifestyle advice that when implemented can optimise health outcomes and reduce associated risks e.g., drug/medication and alcohol use, smoking cessation, foods to avoid, vitamin supplementation etc.
• Underlying medical and/or obstetric problems in the pregnant person, many of which can present a risk to the unborn baby, may not be detected and managed/treated to reduce associated risks.
• The health and development of the unborn baby may not be monitored, foetal abnormalities may not have been detected and opportunities to reduce associated risks may be missed. This is of particular importance where alcohol or substance misuse are a factor e.g., arrangements made for an early induction of labour for an unborn baby that is not growing adequately, or for the birth of an unborn baby with an abnormality to occur in a maternity unit with the specialist neonatal services needed to meet their needs.
• Inappropriate medical advice may be given, potentially harmful medications may be prescribed and medical procedures that are not recommended in pregnancy (such as X-rays) may be undertaken, by medical practitioners who are unaware of the pregnancy.
• Increased risk of maternal complications such as post-partum haemorrhage and neonatal complications such as premature birth and low birth weight
• Increased risk of maternal and neonatal death.
• Increased risk of emotional detachment and poor parent-infant bonding and attachment.
• Opportunities to receive professional advice, support and signposting can be missed.
• Routine enquiry about domestic abuse and referral to specialist domestic abuse support services may not occur. This is of particular importance as domestic abuse is more likely to begin or escalate during pregnancy.
• Parents can be unprepared for the birth of their baby and can find it more difficult to cope with the transition to parenthood.
• Professional opportunities to assess safeguarding need/risk and ensure appropriate support / intervention, such as an early help offer, can be missed.
• Multi-agency safety planning for high risk safeguarding situations cannot be undertaken

In the context of a concealed pregnancy, the effects of going into labour and giving birth can be extremely distressing and traumatic.

An unassisted birth can be dangerous for both the birthing person and baby, due to complications that can occur during labour and birth.

A planned unassisted birth (free birth) is not in itself a reason to refer to children’s services. Pregnant persons who have mental capacity have the right in law to make decisions about their care, even if those decisions are unwise and could put them or their unborn baby at risk.

However, should there be safeguarding concerns other than just the decision to free birth then a referral to children’s services should be made. The routine holistic assessment of safeguarding risk/need undertaken with all pregnant persons is critical to informing this decision.

It is important to distinguish between a pregnant person who is openly making an informed choice to free birth due to their personal preference, beliefs, values and philosophy around childbirth and a pregnant person who is neglecting their unborn babies needs and may be seeking to evade services. The former generally engage with maternity care to some degree.

It is possible that a birthing person not only conceals the pregnancy and birth, but also the baby’s body, should the baby be stillborn or die after birth. Concealing a birth (including a still birth) is a criminal offence, though enquiries into these circumstances should be conducted sensitively and with due regard to the context in which this takes place.

It is also recognised that there will be situations where the birth of a baby is not declared. It is an offence to not register the birth of a child whether born alive or stillborn under the birth registration and death act 1953.

All of the above highlight the need for an increased level of health services and ongoing assessment of birthing person and baby’s well-being, and monitoring safeguarding risks to the child/children in the period following the birth of the baby.

An unborn child has no legal status until the moment they are born. Pregnant persons who have mental capacity have the right in law to make decisions about their care, even if those decisions are unwise and could put them or their unborn baby at risk. Pregnant persons should be given full unbiased information about their options and associated risks and benefits. Where a pregnant person chooses free birth, their choice should be supported, and contingency plans co-produced wherever possible.

If there are concerns that a pregnant person lacks the mental capacity to make the decision to freebirth, decisions may need to be made in their best interests. In such circumstances, legal advice should be sought at the earliest opportunity.

Assessments should identify clear expectations of parents/carers and ensure that should they fail to comply this would constitute a significant risk factor and point to the need to activate further child protection processes and/or Care Proceedings. Under such circumstances legal advice should be sought.

Police must be notified of any child protection inquiries made by children's social care following a concealed pregnancy. Consideration must be given as to whether a joint investigation is needed. This will be dependent upon whether an offence may have been committed or if the child is at risk of significant harm

Action on presentation in labour or following an unassisted delivery of a concealed pregnancy

Action by Maternity Staff

In all cases where a pregnant person arrives at hospital in labour or following an unassisted delivery, as a result of a concealed pregnancy, an immediate referral must be made to children's social care - see Making a Referral Procedure.

The baby should not be discharged until a Strategy Discussion has been held and appropriate assessments undertaken. The Strategy Discussion must consider the initiation of a psychiatric assessment; mental health representation should be included in this strategy discussion.

Where the referral is received out of hours in relation to a baby born as the result of a concealed pregnancy, the Emergency Out of Hours Service will take steps to prevent the baby being discharged from hospital until children's social care have been informed and given their approval for discharge, in most instances this would be until after a Strategy Discussion has been undertaken. The baby should not be discharged out of hours.

Action by Children's Social Care Staff

In situations where a pregnant person presents during labour then consideration should be given to commencing a Section 47 Enquiry.

If a pregnant person presents following unassisted delivery in the context of a concealed pregnancy then a Section 47 Enquiry must commence.

Immediate Protective Actions

In normal circumstances this would be through a voluntary agreement, although clearly there could be circumstances in which it might be necessary to consider an application for an Emergency Protection Order, or to seek the assistance of the Police, e.g. Police Protection, to prevent the child from being removed from the hospital.

In both situations children's social care should consider allocating the assessment to a worker with mental health expertise.

If the child has been harmed, has died or been abandoned, child protection procedures will apply and a joint investigation will be conducted with the relevant police and children's social care team.

Only when the underlying reasons for a previous concealed pregnancy are revealed, explored and addressed, can the risks associated with future concealment be substantially reduced.

Following a concealed pregnancy where significant risk has been identified, children's social care should take the lead in developing a multi-agency contingency plan, to address the possibility of a future pregnancy. This must include a clearly defined system for alerting children's social care if a future pregnancy is reported or suspected.

Where there is a known history of previous concealed pregnancy, professionals should consider referring to Children's Social Care as soon as any subsequent pregnancy is known. People who have already concealed a pregnancy are at an increased risk of doing so in the future. A referral should also be considered when a previous pregnancy was booked late into antenatal care, considering the reasons given and associated risks to the pregnant person and unborn child. An holistic assessment of current safeguarding risk/need will inform decision making.

Where there is a known plan in place, it must be activated as soon as professionals become aware of a subsequent pregnancy. The urgency of the meeting will depend on the stage of pregnancy. It is important that all key professionals working with the family are included. At any stage in the process, consideration must be given to the appropriateness of a full psychiatric assessment.

Effective and timely information sharing is a critical factor in safeguarding pregnant children/young people and the unborn child. Consent to share information for the purposes of safeguarding is not required but, in most circumstances, the pregnant person concerned should be informed, unless doing so would increase the risk e.g., where there is concern that the pregnant person is likely to abscond.